Case Report Initial Presentation of OCD and Psychosis in an Adolescent during the COVID-19 Pandemic
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Hindawi
Case Reports in Psychiatry
Volume 2022, Article ID 2501926, 5 pages
https://doi.org/10.1155/2022/2501926
Case Report
Initial Presentation of OCD and Psychosis in an
Adolescent during the COVID-19 Pandemic
1 1,2
Sahana Nazeer and Abhishek Reddy
1
Virginia Tech Carilion School of Medicine, 2 Riverside Circle, Roanoke VA 24016, USA
2
Department of Psychiatry and Behavioral Medicine, 2017 South Jefferson Street, Roanoke VA 24016, USA
Correspondence should be addressed to Sahana Nazeer; sahana@vt.edu
Received 22 December 2021; Accepted 5 April 2022; Published 15 April 2022
Academic Editor: Lut Tamam
Copyright © 2022 Sahana Nazeer and Abhishek Reddy. This is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work
is properly cited.
The COVID-19 pandemic is unparalleled in recent history when accounting for the true disease burden and dramatic impact on
physical and mental health. Due to its infectious pathology, COVID-19 presents with a variety of symptoms including
neuropsychiatric complications. Moreover, factors such as quarantine, social isolation, and fear of illness have negatively
impacted the health of non-COVID-19 patients. There has been significant literature reporting new-onset psychiatric illness in
all global populations including those without history of psychiatric illness. This report discusses an adolescent male without
prior psychiatric history presenting with new onset symptoms of obsessive-compulsive disorder and psychosis in the context of
COVID-19. There are considerable reports describing new-onset obsessive-compulsive disorder, albeit conflicting in terms of
prevalence and exacerbations in the setting of COVID-19 in both adult and adolescent populations but limited reports of new-
onset psychosis in those same populations and setting.
1. Introduction that neuroinvasive infections such as COVID-19 can
increase the risk of developing psychotic disorders through
The coronavirus 2019 (COVID-19) emerged in Wuhan, inflammatory mechanisms especially during key stages of
China, and as of December 2021, there have been more than physiologic neurodevelopment [6].
270 million confirmed cases, including 5.3 million deaths Obsessive-compulsive disorder (OCD), a relapsing and
[1]. It is widely accepted that these measurements are underes- remitting disorder impacting function, is defined by recur-
timations of the true disease burden. The severe acute respira- rent obsessions and compulsions, of which contamination
tory syndrome 2 (SARS-CoV-2) infection causing COVID-19 and cleaning is common [7]. There was an increase in the
typically presents with respiratory symptoms, but outcomes severity of obsessions and compulsions from the beginning
have ranged from asymptomatic or mild to rapidly fatal. of the pandemic despite remission of OCD symptoms prior
Due to its spike-like glycoproteins attaching to the to the pandemic [8].
widespread angiotensin-conversion enzyme 2 (ACE2), Psychosis is defined by impairment in reality testing,
COVID-19 presents with a variety of symptoms although often including hallucinations without insight and/or delu-
the pathophysiology of SARS-CoV-2’s neuropsychiatric sions leading to functional impairment. It is also reported
complications such as anxiety, psychosis, delirium, and to onset from fear of COVID-19 in patients without prior
depression are yet to be fully determined [2]. It is well psychiatric history [9–14], as exacerbate paranoia in patients
supported that the COVID-19 pandemic has exacerbated with psychiatric history [15], after recovery from SARS-
psychiatric disorders in patients with psychiatric history CoV-2 infection [16], or during a COVID-19 infection
via measures such as quarantine, social distancing, and [17–21]. The onset and worsening of psychosis are associ-
particularly social isolation [3–5]. It has also been reported ated with psychosocial factors such as increased stress from2 Case Reports in Psychiatry
a pandemic, such as the increase in psychosis during the ness. He scored a six on the Children’s Yale-Brown
influenza epidemic [22, 23]. Obsessive-Compulsive Scale (CY-BOCS), but the patient
The exacerbation of mental health concerns, especially minimally participated in the questionnaire displaying para-
anxiety and depression, due to COVID-19 has also been noia and guardedness. He also disclosed intrusive thoughts,
consistently reported [4, 24, 25]. There are conflicting preference for self-isolation, and detailed food selection
reports of the prevalence and onset of OCD in the context methods. The patient was restarted on sertraline 50 mg daily,
of COVID-19 as certain sources state a greater prevalence which was titrated to 75 mg daily prior to discharge; he was
of OCD and worsening of existing OCD symptoms during also provided hydroxyzine 25 mg three times per day as
the COVID-19 pandemic whereas others detail a lack of needed for anxiety. He participated in family, group, and
OCD symptom deterioration [26–28]. Moreover, there have individual therapy. The patient displayed an improvement
been multiple case reports that describe the emergence of in his obsessive thoughts, decrease in intrusive thoughts,
new-onset OCD in both adolescents and adults [29–31] as and lack of handwashing rituals prior to discharge.
well as case reports delineating exacerbations of preexisting After his discharge from his first psychiatric hospitaliza-
OCD during the COVID-19 pandemic [32–34]. tion, the patient gradually resumed his ritualistic cleaning
This case report adds to the growing literature of new- behavior. He self-isolated and engaged in poor self-care,
onset OCD and the minimal literature of new-onset including not showering or wearing clean clothes. The
psychosis in adolescent patients due to COVID-19. We patient was not distressed with the time spent cleaning,
describe an adolescent male without previous psychiatric denied intrusive thoughts of cleaning, and noted that clean-
history who presented with newly onset obsessive- ing did not provide him joy. He denied auditory hallucina-
compulsive disorder and symptoms of psychosis triggered tions. The patient did not meet the criteria for major
by the COVID-19 pandemic. We outline the patient’s depressive disorder at the time. His sertraline was increased
initial presentation, two psychiatric hospitalizations, outpa- to 100 mg daily within two months of discharge from hospi-
tient follow-ups, and gradual improvement. talization. The patient’s cleaning behaviors worsened,
including excessive cleaning that led to the destruction of
2. Case Report products, running washers without items in the machine,
and cooking and eating specific food groups. Although the
A male teenager with no significant previous medical, surgi- patient denied difficulty sleeping, there was concern from
cal, or psychiatric history presented with gradually worsen- his parents that he was sleeping minimally. He displayed
ing isolation and concern about cleanliness for months paranoid and disorganized thinking exacerbated by poor
since the initiation of remote learning secondary to the insight and judgment. Risperidone 0.5 mg nightly was added
severe acute respiratory syndrome coronavirus 2 (SARS- to his medication regimen and increased to 1 mg nightly due
CoV-2) pandemic. The patient had symptoms of repetitive to lack of symptom improvement.
and excessive cleaning of his home, lasting about half the For two months, the patient displayed mild improvement
day, except for his personal bedroom, which remained in cleaning and cooking behaviors, affect, and self-isolation
messy and even dirty. Due to his fear of contamination from in the context of persistent lack of personal hygiene and
the rest of the home, the patient did not wear clothes in nudity at home. He also disclosed anhedonia. There was
other areas of his house except his bedroom and did not ongoing concern for medication nonadherence. At this time,
allow others into his bedroom. Prior to the pandemic, the sertraline was titrated from 150 to 200 mg daily, and risperi-
patient received high grades and participated in extracurric- done was increased to 1.5 mg nightly. The patient reported
ulars. Due to the pandemic, he opted for virtual school and, one month later that he stopped taking risperidone due to
consequently, struggled with his academics. There was no insomnia. Despite reporting a positive mood, the patient per-
reported history of substance use at this time. The patient sistently displayed blunted affect. Sertraline and risperidone
does not have a family history of psychiatric illness and were discontinued, and fluoxetine 10 mg daily was started.
did not have any concern with meeting his early develop- After two months on fluoxetine 10 mg, the patient
mental milestones. He was preliminarily diagnosed with presented with decreased cleaning behavior but still insisted
obsessive-compulsive disorder by his primary care provider on an unhealthy diet that he personally prepares, spent a
and prescribed sertraline 50 milligrams (mg) daily to which minimal amount of time outside of his room, did not wear
the patient was not adherent. clothes inside the home, and refused to brush his teeth
Within two weeks, the patient presented to the emer- consistently leading to cavities. He emphasized that he has
gency department with suicidal ideation in the context of no fear of germs. The patient was also prescribed olanza-
hearing demons. There were no other concerns including pine 2.5 mg daily, but there was persistent concern for
homicidal ideation. Aside from a positive urine drug sample medication nonadherence.
for cannabis, the patient did not present with any medical Due to worsening symptoms over one month, the
illness precluding a psychiatric diagnosis, and thereby, he patient was admitted to inpatient psychiatry for locking
was admitted to inpatient psychiatry for seven days himself in his room due to fear of contamination, not com-
(Table 1). During his first hospitalization, the patient pleting his activities of daily living such as showering and
revealed that the onset of his repetitive cleaning behavior eating, refusing to take his medications and interact with
was prompted by the fear of bringing SARS-CoV-2 home, others, and struggling with anhedonia including academics
although he persistently denied a fear of contracting the ill- for which he failed to move up a grade (Table 1). DuringCase Reports in Psychiatry 3
Table 1: Mental status exam on each admission for the first and second hospitalizations.
First hospitalization Second hospitalization
Appearance Well-groomed. Well-groomed.
Good eye contact. Activity level is
Behavior Eye contact is mostly avoided.
appropriate.
No abnormal movements. Normal
Motor No abnormal movements and no psychomotor agitation or retardation.
gait and station.
Normal rate, rhythm, and volume.
Speech Low rate, tone, and volume. Difficult to hear at times.
Well-articulated.
Mood Appropriate. “When can I get out of here?”
Restricted but appropriate to content
Affect Euthymic, avoidant, and congruent to mood.
and congruent to mood.
Thought
Linear and logical. Poverty of content.
process
Thought Reality-based. Denies auditory and Delusion of “contamination is everywhere.” Auditory and visual hallucinations,
content visual hallucinations. obsessive ruminations and compulsions, and responding internally is not observed.
Suicidal
ideation
Without ideation, plan, or intent. Without self-injurious behaviors.
Homicidal
ideation
Insight No insight. Poor.
Judgment Poor. Poor.
Attention/ Attention is good and concentration is sustained.
Adequate attention. Intact memory.
memory Intact immediate and short-term memory.
Intelligence Average for age based upon fund of knowledge, comprehension, and vocabulary.
his hospitalization, the patient was continued on liquid flu- ences could include severe illness from SARS-CoV-2 or
oxetine 10 mg daily as well as hydroxyzine 10 mg three times known deaths from COVID-19, but just fear of COVID-19
per day as needed and titrated up to olanzapine 5 mg and may not be applicable [37]. The increased stress of the
additionally received melatonin 3 mg nightly for sleep. Lab pandemic, worsened by societal distress, isolation, and wide-
work displayed significantly low vitamin D levels at 7 nano- spread fear, is likely to impact both the etiology and mainte-
grams/milliliter (ng/mL), which was repleted with vitamin D nance of OCD symptoms [38].
2,000 units daily. During hospitalization, the patient’s affect The hypotheses regarding the mechanism of OCD
and communication improved, and he tolerated his medica- symptom exacerbation during the COVID-19 pandemic
tions well without significant side effects supported by an emphasize the impact of hand and surface hygiene as well
Abnormal Involuntary Movement Scale (AIMS) of zero. He as the constant barrage of media warnings reiterating the
displayed gradual improvement evidenced by decreased threat of the disease [28]. Such a fear of SARS-CoV-2 could
obsessions, compulsions, paranoia, and withdrawal from incite symptoms of anxiety and depression, which in adoles-
others. He still only ate certain food groups. He participated cents, is proposed to be mediated by negative emotional
in family, group, and individual therapy well. Upon reactivity [39]. Additionally, there is support that experien-
discharge, he demonstrated improvement in insight and tial avoidance may transform fear of COVID-19 into OCD
judgment without symptoms of suicidal or homicidal idea- symptoms due to cognitive errors [37, 39].
tion, psychosis including hallucinations or delusions, or Regardless of the potentially increased prevalence or
mania. He was discharged with the diagnoses of obsessive- worsening of OCD symptoms, the efficacy of first-line treat-
compulsive disorder and delusional disorder, but early- ment approaches for OCD has not been disproven. Both
onset psychosis due to schizophrenia must still be ruled out. cognitive-behavioral therapy and selective serotonin reup-
The patient will continue follow-up in the outpatient setting. take inhibitors (SSRIs) remain heavily evidence-based treat-
ments [40]. In the work by Alkhamees, the adult patient
3. Discussion responded well to escitalopram within one month [29]. In
the report by Tiuvina et al., the adult patient did not respond
It is well documented that the fear of getting the COVID-19 to hydroxyzine and mirtazapine but had success with a
infection leads to intense experiences such as loneliness, regimen of fluvoxamine and benzodiazepine [31].
stress, anxiety, fear, anger, depression, paranoia, and even There have also been studies that demonstrate the effi-
suicide attempts [3, 35]. Moreover, there is literature cacy of clomipramine, a tricyclic antidepressant, approved
supporting a relationship between adverse childhood experi- for OCD in patients ages 10 and older [30, 41]. In the report
ences and adulthood OCD [36]. Adverse childhood experi- by Sejdiu et al., the adolescent patient initially presented with4 Case Reports in Psychiatry
olfactory hallucinations, which turned out to be a symptom Acknowledgments
of OCD as opposed to psychosis or a neurological process,
that resolved with clomipramine [30]. In this report’s ado- The authors thank Dr. Kiran Khalid for her clinical expertise
lescent patient, his auditory hallucinations may indicate and manuscript edits and suggestions. The Psychiatry and
early-onset psychosis as opposed to a symptom of OCD, Behavioral Department of Carilion Clinic provided financial
hence its resolution with olanzapine. Moreover, given the support for the publication of this article.
patient’s presentation of flat affect, poor eye contact, mono-
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